Total Diet Replacement Within an Integrated Intensive Lifestyle Intervention for Remission of Type 2 Diabetes: Lessons From DiRECT

Abstract

The prognosis for people with type 2 diabetes (T2D) remains concerning, yet its seriousness is often underestimated. T2D is a manifestation, in susceptible individuals, of the disease-process of obesity, and at diagnosis, 10-year survival rates for T2D are around 50%. Here, we will examine: (a) the role of weight loss in T2D, (b) use of total diet replacements (TDRs) to induce weight loss, (c) the Diabetes Remission Clinical Trial (DiRECT) protocol and key results, (d) other dietary interventions related to T2D remission, (e) remission in real life, and (f) future directions. Remission of short-duration T2D will usually require 10-15% body weight loss, and results from the DiRECT trial demonstrated that this can be achieved within routine care in nearly half of all people undertaking a supported, TDR-led behavioural weight management programme. In light of these findings, which have since been replicated in the Diabetes Intervention Accentuating Diet and Enhancing Metabolism (DIADEM-I) trial conducted in the Middle East and North Africa, it is now time to prioritize weight loss programmes for T2D remission from diagnosis, and with increasing acceptance and availability of digital healthcare, there is an opportunity to scale up delivery of remission programmes in a cost effective manner.

Associations of Dietary-Lifestyle Patterns with Obesity and Metabolic Health: Two-Year Changes in MeDiSH® Study Cohort

“…When compared with baseline results, the mean BMI of men with the highest adherence to this pattern remained stable (26.1 kg/m 2 , before and after) and there was no significant increase in the proportion of men with overweight or obesity ( Table S4 ). These findings are very promising, as one of the primary strategies for diabetes remission is weight loss of >10% of body weight [ 43 ]. In our sample we observed an improvement in glycemic control without changes in body weight, suggesting that the diet composition itself may have a protective effect.…”

Commentary: Is there a role for diabetes-specific nutrition formulas as meal replacements in type 2 diabetes?

“…Current gaps in this area of research include identifying the type of formulations and complimentary aspects of a dietary program that yield long-term weight loss maintenance, reduce cardiometabolic risk, and increase the odds of diabetes remission in overweight and obese patients with type 2 diabetes. In this special issue in the Frontiers of Endocrinology , we comment on three key perspective articles that outline (1) the role for diabetes-specific nutrition formulas (DNSFs) as meal replacements in type 2 diabetes management ( 6 ), (2) lessons learned from the Diabetes Remission Clinical Trial (DiRECT) which demonstrated diabetes remission with the use of TDR followed by structured food reintroduction and long-term weight loss maintenance ( 7 ), and (3) use of meal replacements as a temporary option to induce weight loss followed by transition to a dietary pattern that aligns with the values, preferences and treatment goals of the patient ( 8 ). In the first article, Noronha and Mechanick highlight that DSNFs can be used to deliver essential macro- and micronutrients that align with the core nutrition principles from clinical practice guidelines for diabetes prevention and management ( 6 ).…”

“…In the second article, Noronha et al. discuss how body fat accumulation is the dominant driver of type 2 diabetes, and therefore recommend weight loss as the best solution to reduce progression from prediabetes to type 2 diabetes or to achieve remission of type 2 diabetes ( 7 ). For remission to occur, weight loss of > 15 kg is generally needed.…”

“…For remission to occur, weight loss of > 15 kg is generally needed. Bariatric surgery is an option to obtain this level of weight loss, however, this surgical procedure may not be appropriate for all patients ( 7 ). Another option that can be utilized is a low-calorie TDR.…”

“…A nearly identical intervention study (DIADEM-I) also found significant amounts of diabetes remission in the intervention group (61% vs. 12% in the control group) ( 29 ), highlighting the findings were replicable in another population. Overall, the findings from DiRECT and other trials of surgical and non-surgical weight management interventions indicate that a weight loss of 10kg/%, ideally >15kg/15%, is needed for remission and that this should be accomplished as early as possible after diabetes diagnosis ( 7 ).…”